CHAI TOTS SUMMER PROGRAM
                                             ENROLLMENT FORM

 

Child's name
Birthdate
Mother's name
Father's name
Street Address (please include city and zip)
Home Phone
Cell Phone

Mother's Work Phone
Father's Work Phone
Email Address


 

Session Choices Price  
3 Day Option
Monday, Wednesday, Friday		 $1135
5 Day Option
Monday- Friday		 $1890


 

Emergency Contact Information
Child's Name
D.O.B
Address (include city and zip)
Mother's Name
Home Phone
Work Phone
Cell/Pager
Father's Name
Work Phone
Cell/Pager
Family Email

 

 

Allergies
Allergies (food, medical, other)
Pediatrician
Pediatrician's Telephone
Dentist
Dentist's Telephone
Hospital Preferance

 

Emergency Contact
(In case parent cannot be reached)
1. Name
Telephone
Relationship
   
2. Name
Telephone
Relationship

 

Persons authorized for pick-up
Mother yes no
Father yes  no
1. Name
Telephone
Relationship
2. Name
Telephone
Relationship
3. Name
Telephone
Relationship

I give my permission to the Chai Tots Summer Program to use my child's photograph for camp publications and/or publicity.

I authoize Chai Tots Summer Program to act as my agent in obtaining emergency medical treatment for my child in any case where it may not be possible for the school to contact me in sufficient time for such treatment. I Agree to pay any costs that may be charged by the physician or hospital providing such emergency treatment, except when covered by insurance.

A non-refundable deposit of $350 is required for each registration.
please charge my credit card
Credit card number
Expiration date

I will send in a check made out to Chabad of The Rivertowns of $350